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It is a challenging time to be working in health care. There are new care delivery models being developed, declining reimbursements due to price competition and narrowing of insurance networks, and medical practices are consolidating. Meanwhile, use of electronic health record technology has dramatically increased the clerical burden for providers, and staffing is increasingly difficult with national shortages of physicians and nurses in certain specialties. Furthermore, there is constant pressure for health care organizations to implement new quality metrics and requirements for public reporting, along with the ever-present competition to maintain high patient satisfaction scores. (See Shanfelt and Noseworthy 2017.)

Burnout contributes to decreased well-being,
lower retention rates, higher staff turnover,
low morale, and a lack of cohesiveness in the
organization as a whole.

Successfully navigating these challenges requires engaged and resilient leaders and providers who are able to effectively handle both the business aspects and the stress associated with this level of change. Burnout is a key factor impacting the engagement of health care providers across specialty areas:

Approximately 54% of doctors are burned out to some degree, which is an increase from 33-40% of doctors reporting such symptoms just a few years ago.

There is a strong business case for reducing burnout and increasing engagement in health care. Burnout contributes to decreased well-being, lower retention rates, higher staff turnover, low morale, and a lack of cohesiveness in the organization as a whole. Physician burnout has been shown to influence patient care, patient satisfaction and patient safety, and burnout is positively correlated with a physician self-reporting suboptimal care.

One study showed that even just a one-point increase in the exhaustion and cynicism components of burnout resulted in a respective 5% and 11% increase in likelihood of reporting an error. Conversely, hospitals in which burnout was reduced by just 30% had a total of 6,239 fewer infections for an annual cost savings of up to $68 million.

Leaders should focus on both organizational and individual factors, with a recent meta-analysis suggesting that the benefits derived from individual programs would get a boost by also adopting organizational-directed approaches. Three organizational-directed approaches that have been shown to build engagement and reduce burnout are as follows:

Build More Job Resources

Job resources are the motivational aspects of a person’s job that energize. Leaders should focus in these five areas:

Increase autonomy

Foster high-quality connections with colleagues

Create opportunities for excellence (people want to be both challenged and part of something meaningful)

Offer FAST feedback that is frequent, accurate, specific, and timely

Maximize leader support

Minimize Job Demands

Job demands are the aspects of your work that take sustained effort and energy. Not all job demands are created equal, and research points to three specific ones to be minimized because they accelerate burnout and kill engagement:

Role conflict (“I have received conflicting requests from two or more people”)

Role ambiguity (“My duties and work objectives are unclear to me”)

Organizational constraints/unfairness (“I had to go through many hassles to get projects/assignments done”)

Foster Personal Resources

An important personal resource for leaders and their constituents to develop is resilience. Resilience can be taught, and it is built through a set of core competencies that enable mental toughness and mental strength, optimal performance, strong leadership, and tenacity (resilient people give up less frequently when they experience setbacks).

Given the strong connection to patient safety, patient care, and patient satisfaction, it makes good business sense for health care organizations to implement strategies to reduce burnout and build engagement. The time to take action is now.

Do you know of an organization that is taking steps to reduce burnout among health care professionals? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Paula Davis Laack, JD, MAPP, is a lawyer turned stress and resilience expert who works with healthcare organizations and individuals to implement strategies that reduce burnout and build stress resilience. You can connect with Paula at www.pauladavislaack.com.

Burnout and lack of joy in work pose significant risks to health care organizations: 54% of US physicians are burned out and 33% of new nurses seek another job within one year. Burnout is a syndrome characterized by exhaustion, cynicism or depersonalization, and a sense of loss of personal effectiveness.This problem takes a personal toll on health care team members and also seriously impacts patient safety. The correlation between greater engagement and safer patient care is well documented.Reducing burnout results in improved quality, safety, and efficiency with lower turnover rates.

Joy in work occurs when all team members,

no matter their role, find meaning and

purpose in what they do.

Abundant evidence points to leadership behaviors that are an antidote to this significant problem. What leaders do makes a difference in reduced burnout, enhanced teamwork, lower turnover and safer care.

Health care leaders can reduce burnout and achieve safer care by focusing on selected cultural essentials. Through the same leadership actions, they can get a two-for-one outcome: just culture and joy in work. Leaders who ensure just culture behaviors will nurture environments for both safe care and enable colleagues to find joy and meaning in work.

Steps for leaders to integrate just culture and joy in work include:

Definitions of what are they are so everyone has a common understanding

Clear purpose statements of why they are important, which offers a clear focus

Actionsthat describe how we make gains in both

What

Just culture: a learning environment based on respect, trust, and fairness to achieve safe, highly reliable care.

In short, team members will know they will be treated respectfully, consistent with organizational values.

Joy in work: when all team members, no matter their role, find meaning and purpose in what they do. It results when colleagues have an intellectual, behavioral, and emotional connection to the organization’s mission (IHI in press).These environments are characterized by psychological safety. Psychological safety means an environment where all team members feel secure and capable of changing; they experience respectful interactions among all; are able to ask questions, seek feedback, admit mistakes, and propose ideas (Edmondson 2012).

Why

The primary way leaders embed culture is what they pay attention to and how they react to critical incidents (Schein 2004). Leaders are responsible for paying attention to and developing organizational behaviors that promote psychological safety, which enables both engagement and safety.

For instance, of seven drivers of team engagement identified, three are greatly enhanced by psychological safety (Edmondson 2012):

Organizational culture and values are evidenced in the behaviors that are consistent with a just and fair environment. How leaders react to critical incidents involving patient harm is a key behavior that reflects consistency –or lack of– with the intended organizational culture and values.

Social support and community at work are illustrated by respectful interactions among all team members no matter their role. Members feel they can speak up without fear of retribution; are supported by colleagues and leaders to do their best; and experience a sense of camaraderie in their daily work.

Workload and job demands show a balance between the work to be done and the time/resources available. Excessive workload is frequently due to ineffective systems that waste time, energy, and good will. These same ineffective systems lead to unsafe conditions.

How

As part of a well-designed leadership development process, leaders can ask the following organizational assessment questions to further advance their outcomes in safety and joy in work.

How well do we demonstrate just culture principles in every part of the organization?

What happens when an error occurs? What are leaders’ responses? Do the responses vary depending on level of harm or by what role was involved?

Are we as focused on much on system failures as we are on harm events?

Do we act daily to show that respecting others and treating them fairly is essential?

What fairness gaps do we have in our current actions?

Do we promote psychological safety through the following:

oBe accessible, visible and approachable to develop relationships with team members.

oAcknowledge the limits of current knowledge; frame the work as highly complex requiring all to contribute for great outcomes.

oBe willing to show fallibility and humility; acknowledge that we do not have all the answers and are learning.

oInvite participation.

oView failures as learning opportunities.

oUse direct, clear language.

oSet boundaries about what is acceptable behavior and hold others accountable for boundary violation(Edmondson 2012).

This list of what, why, and how is a means of strengthening the leadership journey towards safer care and an environment where joy and meaning thrive.

Burnout among health care professionals is on the rise, as is workplace violence in health care settings. Could efforts to reduce the overlapping organizational contributions to these problems be a strategy to prevention?

Michael Privitera, MS, MD, professor of psychiatry at University of Rochester School of Medicine and Dentistry, has long studied and written widely about this question and related issues. As medical director of the University of Rochester Medical Center Clinician Wellness Program and current chair of the Medical Society of the State of New York Task Force on Physician Stress and Burnout, he also sees the impact of burnout, bullying, and violence firsthand.

“Burnout affects the worker, other staff, the institution, and patients on a daily basis,” says Dr. Privitera. “We can no longer look at burnout as a problem for individual health professionals to solve on their own.”

Workplace violence, while not as common as burnout, includes not only physical harm, but also psychological and emotional harm from bullying, intimidation, or harassment.

Dr. Privitera has found that while the organizational contributors to burnout—such as time and production pressures, changes in technology, and regulatory requirements—are increasingly recognized, some of these same factors may also contribute to increased workplace violence in health care. Likewise, he suggests that some of the same efforts at reducing burnout may also help reduce workplace violence.

“The more we recognize and address overlapping root causes of burnout and workplace violence, the more effective and long lasting our interventions could be,” he says.

Dr. Privitera will speak on this topic at the next Professional Learning Series Webcast, The Overlap between Organizational Contributions to Burnout and Workplace Violence…Is There Overlap of Solutions? Wednesday, December 7, 2:00-3:00 pm Eastern Time. Register at http://bit.ly/burnoutviolence

Chronically high levels of physician distress are creating a dangerous practice environment. Interventions to help reduce clinician burnout need to occur at multiple levels to make our health system safer.

Burnout is a frequent phenomenon across many health care professions, including nursing, medicine, pharmacy, social work, and other roles. Research on physician burnout shows lower levels of patient satisfaction, job satisfaction, and productivity; higher levels of medical errors, malpractice claims, leaving medicine, and early retirement; and higher personal levels of depression, heart disease, suicide, divorce, and substance abuse.

The average burnout rate among doctors in the US has been estimated to be 46%, while only 2% to 4% of physicians are disruptive in the workplace. In many cases of disruptive behavior, burnout from high chronic occupational stress has been found, suggesting a direct relationship between the two. The Joint Commission has issued a sentinel event alert warning that disruptive behavior can compromise patient safety and foster medical errors.

The biopsychosocial model was coined by George Engel to encourage consideration of biological, psychological, and social contributions to and consequences of clinical conditions. Applying this approach, we can see commonalities in cause and inter-relationships between physician burnout, altered safety of medical decision-making, and disruptive behaviors. Social components (health care reform environment, consequent occupational stress when unharmonized and uncoordinated) interact with psychological (rationality in decision-making, emotional control) and biological aspects (intrinsic biology of the physician and changed biology of their body from chronic high levels of stress), which then impacts the community that needs sufficient health care workforce to take care of patients.

Many national, state, government, insurance company, and regulatory agencies separately make mandates that affect the workflow of the physician. However, there is no central agency that oversees their coordination, let alone the harmonizing of these multiple mandates. While expected, it is not known whether full compliance with all mandates is possible.

Example:

Patient: 60-year-old male smoker, new patient to the practice with headache, fatigue, and disturbed sleep, comes in to see a hyper-stressed, burned out physician for a 20-30 minute slot. BP 148/92 Pulse = 96.

Physician behavior: The physician acts based on habit memory, i.e., reflex reactions, hyper-focuses on one symptom—sleep—instead of required cognitive flexible memory involved in pros and cons analysis. Regulatory demands require the physician to counsel on stopping smoking, make sure all Meaningful Use criteria are checked and reviewed, complete new patient history form, populate problem list, cover alcohol and drug use, immunization, preventive measures, and send for old record.

What was missed: Major depressive episode. Insomnia was only one of the symptoms. Patient had suicidal ideation, intent, and plan to kill himself. As a result of poor functioning from his depression, he was about to lose his job. The physician missed the patient’s increased risk of stroke and heart disease from his major depressive episode especially in combination with smoking.

Lack of coordination to unify and simplify health care regulation and mandates draws the physician’s limited cognitive resource away from the intrinsic load being used to solve the clinical problem presented by the patient. The trouble is that no one would argue or attempt to push back when something gets labelled as a “quality” intervention due to the so-called halo effect. The halo effect is a cognitive/confirmation bias where positive feelings get generated toward something ambiguous or unproven. In this case, a quality initiative may lose closer scrutiny to potential impact just because it has the term “quality” attached to it (e.g., a person is wearing a halo, thus this person must be good).

"We as a health care system
need to be concerned about
how much occupational stress
we are imposing on physicians
and other health care professionals
from extraneous cognitive load."

Chronically high levels of physician distress are creating a dangerous practice environment. The irony is that a portion of this distress comes from uncoordinated, unharmonized, and sometimes unproven “quality measures,” which by accumulation actually may be humanly impossible to attain and may even cause harm. Cognitive processes that occur because of excessive stress can lead to medical errors. This neurocognitive issue can be identified as a neurocognitive ergonomic (NCE, sometimes referred to as neurocognitive engineering) problem and is solvable by incorporating NCE principles with new initiative roll outs. Ergonomics is the applied science concerned with designing and arranging things people use so that the people and things interact more efficiently and safely (also called biotechnology, human engineering, human factors). Neurocognitive ergonomics applies ergonomic principles that use knowledge of brain function and thinking processes to lower cognitive strain and improve efficiencies.

We as a health care system need to be concerned about how much occupational stress we are imposing on physicians and other health care professionals from extraneous cognitive load. Our society has made the connection between cognitive workload and the safety of recipients of services in such professions as nuclear power workers, air traffic controllers, airline pilots, and others. It is becoming clear that physicians, nurse practitioners, physician assistants, and nurses need to be on this list for both their own and the patient’s safety.

Burnout is both preventable and reversible, which gives us an opportunity to provide support on two levels:

The individual level, by promoting clinician’s physical and mental health

The institutional level by decreasing sources of occupational stress through improved design, improving efficiencies of workflow, finding ways as an organization to reduce administrative burden on clinicians, and allowing bottom-up input in decisions that affect the practice environment

Urie Bronfenbrenner describes an ecosystem model that is relevant to conceptualizing the health care ecosystem. Various levels interact with each other and create feedback systems affecting the other levels:

a) Macro-level—national, state, insurance industry level decisions
b) Meso-level—health care system level decisions
c) Micro-level—individual physician and patient interaction in delivery of care
d) Exo-level—the interaction of physician with his or her family and with others in the community.

Interventions to help reduce burnout need to occur at all four levels to help more rapidly reduce the extent of burnout that exists.

In summary, there are certain things that we cannot take away from the cognitive workload of physicians that are intrinsic and germane to the practice of medicine. What we can change (by better design) is to be very careful and parsimonious about administrative, mandate, and regulatory demand. (See Table 1 below for suggestions for safer implementation of innovations in health care.) We can do a better job of being clearer and selective about what the essential and relevant quality issues are, what should be universally used, and what should be only indicated by the clinical situation, especially when implementing innovations in the health care system. We need to bear in mind the physical, emotional, time, and cognitive limitations that humans (who happened to be trained as physicians) have. In doing so we will be improving the safety of our health care workforce, which then is inextricably linked to the safety of our patients.

Table 1

Suggested Questions for Safer Implementation of Innovation in Health Care:

Is there evidence that what we are suggesting as a new innovation in healthcare delivery—by itself—does not cause harm and in fact creates enough benefit to be worth the risk of imposing it on a currently time-challenged, overburdened, and burned-out healthcare workforce?

Has the new innovation in delivery accounted for existing demands on the physician plus any new demands put upon them by other agency new innovation demands?

Has there been sufficient collaboration between authoritative agencies with each other and the front-line providers of care, being respectful of each other’s concerns and intentions?

Are there built in fail-safe mechanisms with the innovation to allow for mid-stream corrections in course? This requires the implementation of the suggestions in Question 3.

Conceptual Issues for Discussions:

Awareness of down-steam consequences that occur by accumulation of unharmonized duties

Efforts to assess and recognize potentially negative impact on delivery of physician services before policy decisions are agreed upon

Efforts for stakeholder agencies to better coordinate plans and logistics

Are there ways in the meantime to have authoritative sources of mandates and regulations to attempt a collaborative effort? The goal would be to pare down the total cognitive load on the physicians to a safer level

Alan H. Rosenstein, MD, MBA, is an educator and consultant in health care management based in San Francisco, CA.
Submit correspondence about this article to Dr. Privitera at Michael_Privitera@urmc.rochester.edu